|
BIPOLAR LINER 50/51/52MMODX28M
|
Facility
|
OP
|
$875.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$446.25 |
| Max. Negotiated Rate |
$848.75 |
| Rate for Payer: Cash Price |
$525.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$831.25
|
| Rate for Payer: Health Management Network Commercial |
$743.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$551.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$446.25
|
| Rate for Payer: MDX Hawaii PPO |
$848.75
|
| Rate for Payer: University Health Alliance Commercial |
$637.79
|
|
|
BIPOLAR LINER 50/51/52MMODX28M
|
Facility
|
IP
|
$875.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$743.75 |
| Max. Negotiated Rate |
$848.75 |
| Rate for Payer: Cash Price |
$525.00
|
| Rate for Payer: Health Management Network Commercial |
$743.75
|
| Rate for Payer: MDX Hawaii PPO |
$848.75
|
|
|
BIPOLAR LINER 50MM OD X 22MM
|
Facility
|
OP
|
$875.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$446.25 |
| Max. Negotiated Rate |
$848.75 |
| Rate for Payer: Cash Price |
$525.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$612.50
|
| Rate for Payer: Health Management Network Commercial |
$743.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$551.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$446.25
|
| Rate for Payer: MDX Hawaii PPO |
$848.75
|
| Rate for Payer: University Health Alliance Commercial |
$490.00
|
|
|
BIPOLAR LINER 50MM OD X 22MM
|
Facility
|
IP
|
$875.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.00 |
| Max. Negotiated Rate |
$848.75 |
| Rate for Payer: Cash Price |
$525.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$612.50
|
| Rate for Payer: Health Management Network Commercial |
$743.75
|
| Rate for Payer: MDX Hawaii PPO |
$848.75
|
| Rate for Payer: University Health Alliance Commercial |
$490.00
|
|
|
BIPOLAR SHELL #00-5001-048-00
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$535.50 |
| Max. Negotiated Rate |
$1,018.50 |
| Rate for Payer: Cash Price |
$630.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$735.00
|
| Rate for Payer: Health Management Network Commercial |
$892.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$661.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$535.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,018.50
|
| Rate for Payer: University Health Alliance Commercial |
$588.00
|
|
|
BIPOLAR SHELL #00-5001-048-00
|
Facility
|
IP
|
$1,050.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$588.00 |
| Max. Negotiated Rate |
$1,018.50 |
| Rate for Payer: Cash Price |
$630.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$735.00
|
| Rate for Payer: Health Management Network Commercial |
$892.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,018.50
|
| Rate for Payer: University Health Alliance Commercial |
$588.00
|
|
|
BIPOLAR SHELL 43MM OD
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$535.50 |
| Max. Negotiated Rate |
$1,018.50 |
| Rate for Payer: Cash Price |
$630.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$735.00
|
| Rate for Payer: Health Management Network Commercial |
$892.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$661.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$535.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,018.50
|
| Rate for Payer: University Health Alliance Commercial |
$588.00
|
|
|
BIPOLAR SHELL 43MM OD
|
Facility
|
IP
|
$1,050.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$588.00 |
| Max. Negotiated Rate |
$1,018.50 |
| Rate for Payer: Cash Price |
$630.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$735.00
|
| Rate for Payer: Health Management Network Commercial |
$892.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,018.50
|
| Rate for Payer: University Health Alliance Commercial |
$588.00
|
|
|
BIPOLAR SHELL 46MM OD
|
Facility
|
OP
|
$1,050.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$535.50 |
| Max. Negotiated Rate |
$1,018.50 |
| Rate for Payer: Cash Price |
$630.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$997.50
|
| Rate for Payer: Health Management Network Commercial |
$892.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$661.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$535.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,018.50
|
| Rate for Payer: University Health Alliance Commercial |
$765.35
|
|
|
BIPOLAR SHELL 46MM OD
|
Facility
|
IP
|
$1,050.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$892.50 |
| Max. Negotiated Rate |
$1,018.50 |
| Rate for Payer: Cash Price |
$630.00
|
| Rate for Payer: Health Management Network Commercial |
$892.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,018.50
|
|
|
BIPOLAR SHELL, 52MM
|
Facility
|
OP
|
$2,090.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,065.90 |
| Max. Negotiated Rate |
$2,027.30 |
| Rate for Payer: Cash Price |
$1,254.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,463.00
|
| Rate for Payer: Health Management Network Commercial |
$1,776.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,316.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,065.90
|
| Rate for Payer: MDX Hawaii PPO |
$2,027.30
|
| Rate for Payer: University Health Alliance Commercial |
$1,170.40
|
|
|
BIPOLAR SHELL, 52MM
|
Facility
|
IP
|
$2,090.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,170.40 |
| Max. Negotiated Rate |
$2,027.30 |
| Rate for Payer: Cash Price |
$1,254.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,463.00
|
| Rate for Payer: Health Management Network Commercial |
$1,776.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,027.30
|
| Rate for Payer: University Health Alliance Commercial |
$1,170.40
|
|
|
BIPOLAR SHELL, 55MM
|
Facility
|
OP
|
$2,272.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,158.72 |
| Max. Negotiated Rate |
$2,203.84 |
| Rate for Payer: Cash Price |
$1,363.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,590.40
|
| Rate for Payer: Health Management Network Commercial |
$1,931.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,431.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,158.72
|
| Rate for Payer: MDX Hawaii PPO |
$2,203.84
|
| Rate for Payer: University Health Alliance Commercial |
$1,272.32
|
|
|
BIPOLAR SHELL, 55MM
|
Facility
|
IP
|
$2,272.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,272.32 |
| Max. Negotiated Rate |
$2,203.84 |
| Rate for Payer: Cash Price |
$1,363.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,590.40
|
| Rate for Payer: Health Management Network Commercial |
$1,931.20
|
| Rate for Payer: MDX Hawaii PPO |
$2,203.84
|
| Rate for Payer: University Health Alliance Commercial |
$1,272.32
|
|
|
BIPOLAR SMALL SHELL 49MM
|
Facility
|
IP
|
$2,278.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.68 |
| Max. Negotiated Rate |
$2,209.66 |
| Rate for Payer: Cash Price |
$1,366.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,594.60
|
| Rate for Payer: Health Management Network Commercial |
$1,936.30
|
| Rate for Payer: MDX Hawaii PPO |
$2,209.66
|
| Rate for Payer: University Health Alliance Commercial |
$1,275.68
|
|
|
BIPOLAR SMALL SHELL 49MM
|
Facility
|
OP
|
$2,278.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,161.78 |
| Max. Negotiated Rate |
$2,209.66 |
| Rate for Payer: Cash Price |
$1,366.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,594.60
|
| Rate for Payer: Health Management Network Commercial |
$1,936.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,435.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,161.78
|
| Rate for Payer: MDX Hawaii PPO |
$2,209.66
|
| Rate for Payer: University Health Alliance Commercial |
$1,275.68
|
|
|
BIPOLR SHELL 47 00-5001-047-00
|
Facility
|
OP
|
$1,225.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$624.75 |
| Max. Negotiated Rate |
$1,188.25 |
| Rate for Payer: Cash Price |
$735.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$857.50
|
| Rate for Payer: Health Management Network Commercial |
$1,041.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$771.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$624.75
|
| Rate for Payer: MDX Hawaii PPO |
$1,188.25
|
| Rate for Payer: University Health Alliance Commercial |
$686.00
|
|
|
BIPOLR SHELL 47 00-5001-047-00
|
Facility
|
IP
|
$1,225.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$686.00 |
| Max. Negotiated Rate |
$1,188.25 |
| Rate for Payer: Cash Price |
$735.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$857.50
|
| Rate for Payer: Health Management Network Commercial |
$1,041.25
|
| Rate for Payer: MDX Hawaii PPO |
$1,188.25
|
| Rate for Payer: University Health Alliance Commercial |
$686.00
|
|
|
BISACODYL 10 MG RECTAL SUPPOSITORY [1080]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 71399846002
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
BISACODYL 10 MG RECTAL SUPPOSITORY [1080]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 00574705012
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
BISACODYL 10 MG RECTAL SUPPOSITORY [1080]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 45802071030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
BISACODYL 10 MG RECTAL SUPPOSITORY [1080]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 71399846002
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
BISACODYL 10 MG RECTAL SUPPOSITORY [1080]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 45802071030
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
BISACODYL 10 MG RECTAL SUPPOSITORY [1080]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 00574705012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
BISACODYL 5 MG TABLET,DELAYED RELEASE [1079]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904640761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
